The Medical Monopoly: A Letter to the New York TimesE. A. Stead, Jr.
5113 Townsville Road
Editor of the New York Times:
Is the monopoly that the medical colleges have on how we educate our doctors driving up the cost of health care? Each day I read of failures of our health care systems. Numerous private and public agencies are studying the problem. Every study group will be dominated by faculty members from our most prestigious medical schools. These faculty members have high incomes and relatively few patients. The faculty members are reimbursed for travel, food and hotel plus a moderate fee for time away from the medical school. The doctors staying at home, caring for 99.9% of the people, do not have the time to worry about the future of health care. Their problem is how to survive this day and next month.
Most economists believe that absolute monopolies are undesirable and our laws allows them to be broken up. Many of us remember the legal actions leading to the breakup of the Rockefeller oil empire and the tobacco trust of James B Duke. Most of us do not know that one group of civilian institutions has established an absolute monopoly which can only be broken up by repealing laws in all of our states. All states require applicants who will be given the privilege of practicing medicine to pass state approved qualifying examinations. At first glance this may seem reasonable. The catch is that no American citizen educated in our country can sit for the qualifying examinations until he or she has graduated from an accredited medical school. The monopoly is absolute and can not be broken nationally without changes in the laws of all states. Interestedly enough any accredited medical school already has the power to break the monopoly without breaking any of the rules. Self interest and the desire for money and power prevent an accredited medical school from moving away from the pack. Once a medical school is accredited it has the privilege of filling its classes with students who have graduated from a four year college. It can accept students for advanced standing and award the M.D. degree whenever the school believes that the student is ready for the qualifying exams. About 35 years ago before the age of space exploration the market for Ph.D. graduates collapsed while the market for M.D. graduates remained robust. One of the Florida medical schools decided that the first two years of the Ph.D. program covered the sciences which supported medical practice and accepted the Ph.D. students into the third year class of the medical school. In my role as physician-in-chief of Duke hospital I appointed several of these former Ph.D. candidates to the resident staff. They performed as well and in some instances better than the students who had spent 4 years in the medical school.
In general the leaders of the monopoly sleep well. They have never been formally challenged. After all they are so important and they are the only people with power and financial resources and time to produce change. Our monopoly for ever!!!
In fairness to the medical schools all of the allied health disciplines have developed as vertical spikes and they have traditionally made no provision to allow horizontal movement. If one desires to broaden his base and climb another vertical spike one must start at the bottom of the new spike and no credit is given for any past learning.
Accepting the fact that our attempts to break the medical school monopoly have failed, we have offered a way around it that in theory would leave the monopoly in tact. To understand our proposal you will need to know some thing about medical schools and their educational programs. Medical schools traditionally require 4 years of course work in an accredited college. Most parents do not know that medical schools traditionally accept students from a relatively few colleges. Send John or Mary to most colleges and your hopes for an M.D. will not come true. The colleges sending the most students to medical schools are in fact close allies of the medical school monopoly. The close tie between favored colleges and the medical schools was emphasized to me by Goodrich White ,The President of Emory University. His 33 year old professor of medicine and department chair had told a reporter of the Atlanta Constitution that the medical school did not need to require 4 years of college work. Two years were adequate. This would allow the students not interested in additional college work to graduate two years earlier and give them time for two additional years of postgraduate study either here or abroad. I gave my talk on Saturday night and to my surprise it was headlined in the Sunday morning paper. I was even more surprised to receive a six thirty call from President White. "Young man ! Meet me in my office at 7 o'clock." I suggested that we might meet for breakfast. He replied that he had no interest in food and wished to close the conversation.
He sat me in a chair and told me that I would be fired if I ever again in any way suggested that the medical students did not need 4 years of undergraduate education. 75% of the students enrolled in our undergraduate classes come here because it is well know that medical schools favor Emory graduates. Emory cannot survive if we lose the money paid by the third and fourth year premedical students. A young idealist professor became wiser and less idealist. We have already made the moves that would break the medical monopoly if it was not protected by state laws. To understand the present situation you need to know more about the educational programs of accredited medical schools. They divide the 4 years of required work into two sections. The sections, preclinical and clinical, are each 2 academic years in length.
The course work in the preclinical years is designed to give the students a working knowledge of the current state of the biological sciences which relate to curative and preventive medicine. The student spends 2 years memorizing scientific facts to assure that he can pass the state qualifying examination given at the end of two years. The faculty for the preclinical years has several unsolved problems. The faculty receives some university funds but the main sources of funding is from government agencies, health care related industries, foundations, and the super rich like Bill Gates. To keep these rich sources of money flowing the preclinical faculty put most of their energy into highly specialized research programs. Each senior faculty member has a number of students enrolled in the graduate school who are learning how to conduct independent research which will qualify them to receive the Ph.D. degree. These bright and ambitious graduate students and the research oriented preclinical professor are the team that produces the new knowledge and keep the money flowing. You do not have to be a mental giant to figure out who is dearest to the professor -medical student or graduate student.
The preclinical faculty has a second disadvantage. Never having practiced medicine or cared for patients they have no way of knowing what areas need special attention. They are afraid to leave out anything. What if a patient died because my lectures omitted a certain fact. The third problem is lack of follow up. The faculty member knows what the student has memorized when his course ends. He has no way of knowing what is remembered a month later. As far as I know I am the only faculty member who worships and communes with the memory curve ever morning before breakfast. This curve has licked every preclinical medical faculty. I am not unsympathetic. Knowledge and facts increase exponentially. They are the sum of many minds. The human brain is the extension of the output of one egg and one sperm. No wonder that the collective knowledge base changing rapidly puts great strain on a single brain which has little capacity to change its structure.
Putting the name medical on any thing quadruples the cost. Many excellent colleges have strong science faculties who enjoy students and prize the opportunity to watch them grow in stature. Mount Holyoke college comes to mind. This excellent college could prepare its undergraduate science majors to take the first qualifying examination required by the states. Their friends going the traditional route of four years of college could remain at Mount Holyoke for an additional two years and receive a masters degree in the sciences related to clinical medicine. If the medical monopoly were broken the Mount Holyoke graduates would enter medical schools as third year students. What a saving in time and money. The best years in a doctors life are the 5 years after graduation from school.. I was seven years in a white suit and I prize those years over all others.
In October. 1941 I was 32 years of age and a member of the faculty of the Harvard Medical School with the rank of associate. I was also a Captain in the newly formed Brigham Hospital Unit headed by Eliot Cutler; Surgeon-in -chief of the Brigham Hospital. He told us to prepare for a long war and correctly predicted that the Brigham Unit would be the first unit sent overseas. I have a picture of Cutler signed to Eugene Stead, Physician And Surgeon. It is not for sale. In that same month I was asked to come to Emory as Professor of Medicine and Chairman of the Department. I was to be in residence in Atlanta by May 1944. To my surprise, with no help from me, Emory managed my discharge from the unit. I accepted the Emory offer with the provisor that I would not volunteer for service, but that I would not make any move to avoid service. Emory -not I -would be in charge.
To my surprise all of my Harvard friends thought that I had lost my mind. Emory and Grady Hospital have destroyed the academic careers of a series of bright young men. You have a bright future at Harvard. Please stay put. My chief and idol Soma Weiss thought differently. "You can stay comfortably at Harvard and probably in time attain the rank of Professor. Can one person greatly influence a unit the size of Harvard-- only rarely. I rank you as a man of great promise. Emory needs you and if you can crack that wilderness you will have become a man of achievement. If you fail Atlanta will have an excellent practicing physician. Go for it." I did. A new crop of interns and residents usually report for duty on July 1 but with the war under way the number of interns and residents assigned to a given hospital was sharply reduced. The number assigned to Grady could not cover the services. I would be telling students how to care for patients. They would find that theory and practice had separated. Medical Care on my medical wards would be lousy. I was in an unusually difficult position because I never lectured.
Each morning the interns, medical students, residents, nurses and I worked with patients to find out what they wanted from us. We then worked to determine whether our group could meet the needs of the patient. We had the knowledge and skills to give immediate care to the most pressing problems, but as we discussed the management of the patients over the next week many questions arose for which our group had no answers. Each member including myself was assigned a question to be answered at our rounds the next day. The system worked because the group knew that around midnight they could find me in the library searching for the answer to my question. Remember in normal times it took 4 years in college and 4 years in medical school to obtain the MD degree. During the war the college requirement was cut to 2 years, time in medical school to 27 months.
The answer to my problem of how to give excellent medical care to the very sick patients on my medical wards was very simple. Explain to our students that their student days were over. From now on they would function as doctors. They would live in crowded resident quarters and be on call day and night. Anyone had the privilege of refusing to accept the promotion and remain as a student. In a very short time the armed services would order my reluctant student to active duty and my problem would be solved.
Every one joined in. The student doctors saw the patients first and recorded the patients story and his findings. Within the next 8 hours a resident or faculty member met with the patient and the student doctor to review the written record and to check the most important findings. Any errors in the record were corrected. At times the student doctor stood his ground and the record recorded his disagreement. That student invariable received an A+ when I learned of the incident. Even I was amazed at how quickly our student doctors became real doctors. They were now playing for keeps and were very proud of their achievements.
Accepting the fact that the public does not know that no significant changes in medical care will occur until the monopoly is broken, and that our political leaders are unaware of the medical school monopoly , we have outlined a program that would allow a single medical school to by pass the monopoly. The medical school that implements our program will be the first truly international medical school. It will have students from every country in the world. It will always be remembered as the leader that made medical care available at a reasonable price. Being first is very satisfying. Why is The Duke PA School the only unit of the Duke Medical Complex that is always rated number 1? Duke was first.
The Program That Will Win
An accredited medical school will establish an online division that allows its students to take courses at home or at work. The purpose of the online division is to allow Physician Associates and Nurse Practitioners holding a Masters degree to take the courses needed to meet the requirements of the medical school for the M.D. degree. Those up graded students would sit for the qualifying examinations along side of the graduates of the traditional 4 year school. This would allow an easy comparison of the two methods of education. If the percentage of the upgraded students passing the examinations equaled or was greater than that of the traditional 4 year program the online program would be judged to be successful. Past experience shows that older students, knowing why they are in school and anxious to make for lost time, perform better than the younger students. The online medical school will set the requirements for admission. We suggest the following: Physician associates and nurse practitioner who are 27 years of age and have a masters degree whose course of study included one year of the sciences underlying medical practice and one year of student apprenticeship covering the areas covered by the traditional M.D. rotating internship. The final requirement is that the candidate has completed 3 years of practice under the supervision of a practicing M.D. or a group of M.D.'s. willing to write strong supporting letters.
I know from past experience that the nursing hierarchy will resent the upgrading of the nurse into the M.D. provinces but I can not think of any other way to go. Once the nurse practitioner has the M.D. degree she is free as bird. I know of no other way for the nurse to be able to take advanced training in the medical and surgical specialties. If the nurses cannot crack the present glass ceiling under which the profession now operates, the profession will continue to experience a declining pool of applicants to nursing school. This proposal offers nurses one way to destroy the glass ceiling. I can think of no other way. I will support them in any program that will crack their glass ceiling. To date I have found no medical school that is willing to offer online courses. Indeed the one thing that members of the monopoly fear is that a small school might break ranks and cause the entire edifice to crumble. Small schools will never move. They had a hard time becoming accredited. They wished to lie as low as possible .
There have been many studies that have shown that physician associates operating as a part of the physicians team give services equal to that of the supervising doctors. This proposal is based on sound educational principles. It is unacceptable to the medical schools because it would destroy their monopoly sustained by state law. We intend to take our proposal to the people who can force the politicians to break the present log jam. I hope that the first medical school to implement this program will remember that the goal of this new program is to increase the number of practicing doctor in rural and under served areas as rapidly and cheaply as possible. I would start the on line program with 20 students who would spend one week on the medical school campus in the summer before they matriculated in the online program. The online dean with the help of the traditional medical school faculty would determine what additional courses each of the twenty on line students needed to be able to pass the qualifying examinations. These students could take both of the qualifying examinations in the same week. The three years of practice during which time the online students cared for patients every day would give our on line students at sitting for the qualifying examinations clinical skills and knowledge far beyond that possessed by students graduating from the usual on campus four year medical school. I will let the readers figure out the amount of money saved by taking the online course. I have loved the New York Times for many years. This is the first letter that I have offered the Times. I will glow with pride if it is printed. On the other hand (as the good book says) my interest may be better served if the Times sides with the medical monopoly and refuses to publish. In that case I can E mail 1000 copies to appropriate persons asking would you like to read a letter about the present state of health care that The Times is afraid to publish . Since I can not decide what is in my best interest I must leave the choice to you.
Eugene A Stead, Jr.
Distinguished Professor of Medicine Emeritus, Duke University Medical School
Charter Member of the Institute of Medicine
Creator of the Physician Assistants-Associate Programs